Adult Services

Adult ENT specialist in Singapore

Dr Lynne Lim is recognized as one of the top adult Ear Nose Throat specialists island wide. She specializes in ear disorders as well as the surgical and non-surgical correction of hearing loss, which also entails different types of treatments, and the insertion of cochlear and middle ear hearing implants. In addition to this, her repertoire also includes a comprehensive range of investigations and the effective management of different adult ear conditions. Hearing impairment can afflict a majority of people, and is usually underestimated due to lack of public awareness and the fear of stigmatisation. Hearing loss is associated with social isolation, inability to communicate with friends and loved ones, depression, and reduced safety. It is also increasingly, being linked with dementia and memory problems.

Dr Lynne is one of the best adult ENT doctors in Singapore managing holistically the full spectrum of ear, nose and throat disorders.

Ear / Balance
Conditions managed:
  • Adult ear conditions could have arisen from Congenital infections/ Syndromes, Genetic, Microtia/ Atresia and Central Auditory Processing Disorder (CAPD) causes as for children (refer Children Services).
  • Age-related hearing loss – Natural wear and tear with degeneration of the inner ear and middle ear function is common in adults over 50 years of age, warranting screening for hearing loss. It is accelerated by noise exposure, certain drugs, infections and genetics.
  • Noise-induced hearing loss – This is due to very high noise level exposure for just a few minutes, or chronic high noise exposure. Some patients are more at risk due to genetics or poor general health e.g. hypertension and diabetes.
  • Tinnitus – This is a result of hearing loss and may also occur due to tumors, abnormal vessels, thyroid dysfunction and drugs.
  • Lumps and sinuses around/ on the external ear – These may be simple sebaceous cysts, keloids, pseudocysts or congenital preauricular sinuses.
  • Ear wax – Impacted ear wax can cause discomfort and hearing reduction.Photo 21  Glue Ear
  • Otitis media – This can be acute, painful or accompanied with fever when associated with infections. When it is chronic with fluid in the middle ear, a nasopharyngeal carcinoma has to be excluded in adults.
  • Eustachian tube dysfunction – This can be due to anatomy, tone, nasal allergies or infections causing blocked ear sensations especially during descent of airplanes and at times of colds/ flu.
  • Perforated ear drum – This can result from traumatic injury to the ear drum or chronic untreated middle ear and mastoid infections.
  • Middle ear bones pathology - Malformed, dislocated, fractured, eroded, and fixed e.g. otosclerosis (fixed stapes). This can be congenital, traumatic, or due to chronic infection or tumor
  • Cholesteatoma – A middle ear tumor that is not cancerous, but causes hearing destruction by eroding middle ear bones and bringing about toxin penetration to the inner ear. May erode into brain, face nerve and ear balance organs.
  • Malignant Otitis Externa – Bacterial infection of the ear canal and temporal bone causing deep pain and chronic ear discharge, often associated with diabetes.
  • Mastoid infection – Chronic infection of the mastoid air cells and bony septations due to bacteria, fungus or unusual diseases like Tuberculosis.Photo 22 Acoustic neuroma on MRI
  • Acoustic Neuroma – Tumor of the hearing nerve impairs hearing, and may cause facial nerve palsy, giddiness and increased intracranial pressure with growth.
  • Giddiness – This is due to disorders in ear balance organs in about 30% of cases. This usually due to infections, Meniere’s Disease, Benign Paroxysmal Positional Vertigo (BPPV) and trauma. Other causes include drugs, brain, neurological, metabolic (e.g. sugar levels), heart and hormonal causes.

 

Significance:
  • Hearing loss is often missed, and many do not seek treatment from an adult Ear Nose Throat specialist in Singapore for fear of stigmatization or deeming that it is not important.
  • Many adults do not know they have hearing loss. It is often associated with ringing ears. Only 1 in 10 of adults requiring hearing aids uses them. There is a delay of diagnosis of 10 years on average. Beyond just increasing the risk of social isolation, depression and falls, hearing loss is now associated with memory/ cognitive impairment and dementia. In the National Health Survey 2010 study Dr Lim assisted with, 1 in 4 between 50-59 years of age; and 2 in 5 adults between 60-69 years old already have hearing loss. With each additional 10 years of life, the incidence increases dramatically.
  • Many teenagers and young adults underestimate their noise exposure and the risk of noise-induced hearing loss. Many in professional jobs with noise exposure do not use hearing protection even if available. Have you had ringing ears after a cinema or clubbing event? That may indicate hearing loss that often starts at high frequencies. Listening to your music via headphones at maximum volume risks hearing loss in less than an hour.
Investigations offered:

The hearing tests and complete range of services are available in-house in sound-proof and sound-treated rooms, allowing the adult Ear Nose Throat doctor to interpret the tests together with the audiologist to offer a treatment plan on an immediate basis. Closer collaboration also allows for increased safety of investigations requiring sedation, and optimizes outcomes.

  • Otoscopy and light microscopy – Otoscopy offers clear views of the ear canal and ear drum. Light microscopy magnifies these images many times and with increased clarity for diagnosis.
  • Adult hearing test – Pure tone hearing test, with and without hearing aids, speech discrimination, acoustic reflex threshold
  • Eustachian tube dysfunction test – this can confirm if your inability to pop the ears or pressure pains especially on airplane descent or in lifts are due to a dysfunction of the cartilaginous-muscular tubes that connect your middle ears to the back of the nose
  • Tympanometry – this test shows the middle ear pressure and volume, and is a reflection of the state of the ear drum and middle ear. It is often flat in patients with fluid or pus in the middle ear.
  • Radiology: CT scan temporal bone, MRI brain and Internal Acoustic Meatus are required to determine the anatomy of bony and soft tissue structures of the outer, middle and inner ear, cochlear, vestibular aqueduct, hearing and facial nerves and the brain. This also excludes infections and tumours.
  • Genetic testing: There are over 200 types of genetic hearing loss. Contrary to common perception, 75% of newborns or young with hearing loss do not have parents or relatives with hearing loss. The only way to exclude genetic cause is to do an appropriate blood test guided by history. In Singapore, 40% of patients with unknown cause of hearing loss and other body systems normally have a Connexin 26 gene mutation. Knowing the genetic cause guides management over a lifetime, as there may be associated eye, kidney, heart or thyroid problems. It also suggests the progression and prognosis of hearing loss, besides helping families interested in determining the chances of hearing loss in future offspring.
  • Tinnitus testing: Hearing tests include high frequencies testing. A Tinnitus Questionnaire and Tinnitus pitch matching.

 

Treatments Offered

NON-SURGICAL

  • Topical ear drops, oral medications, and temporary cotton stents can help ear wax, and infectious, traumatic causes.
  • Gentle ear cleaning and culture sensitivity of infection fluids, removal of wax and foreign bodies under light microscopic visualization and fine instrumentation.
  • Hearing aids from a wide range of brands, sizes, types and degrees of sophistication
  • Offer customized choices for different ages and listening situations.
  • FM systems for classrooms and halls to improve on HA performance.
  • Tinnitus treatment – Treating and rehabilitating hearing loss helps (e.g. with a hearing aid). Psychological counselling, avoidance of stress factors and stimulating substances ( e.g. caffeine), tinnitus maskers, Zen Tones, Neuromonics and others.

SURGICAL

  • Non GA clinic procedures to help release pus or fluid from the middle ear in adults.
  • Under GA (day surgery) to release fluid or insert grommet tubes for glue ears, repair perforated ear drums, reconstruct or replace with simple prostheses for malformed or eroded ear bones/ stapes as in otosclerosis
  • Under GA to remove ear tumors that could be malignant or benign e.g. cholesteatoma
  • Under GA to remove chronic or dangerous mastoid ear infections via tympanomastoidectomy.
  • Under GA for inserting various implants like bone anchored hearing aids, bone anchored hearing implants, middle ear implants for moderate-severe or mixed hearing loss, single-sided deafness and atresia of ear canal.
  • Under GA to insert cochlear implants for profound sensorineural hearing loss. Choice of Advanced Bionics, Cochlear and MedEl implants.
  • Under GA for microtia and atresia surgery
    • For hearing: possible reconstruction of ear canal (canalplasty) and malformed ossicles (ossiculoplasty), or bone anchored hearing aids/ bone anchored active implants, or middle ear implants
    • For outer ear auricle reconstruction: choices include a prosthetic ear, Medpore (artificial graft) or patient’s own rib graft in the first stage, followed by the second stage with split skin graft from the abdomen and superficial temporal artery revascularisation.

 

Nose / Sinus/ Allergy
A. Epistaxis

Causes:

Nasal causes include trauma, infection and tumor. Systemic causes include blood disorder, hypertension, and drugs that reduce the ability to clot properly, eg warfarin and aspirin.

Investigations offered:

Anterior nose can be examined with speculum and good headlight. Posterior nose and postnasal space would require flexible nasoendoscopy. Blood tests to exclude systemic causes.

Treatments offered:

  • Local pressure on the anterior nose is taught for anterior nose bleed
  • Topical silver nitrate cautery or diathermy to seal the small bleeding capillaries
  • Nasal packing with Merocel, Surgicel, ribbon gauze or balloon for severe bleeds
  • Selective endoscopic arterial ligation/ embolisation

 

B.  Allergic rhinitis, sinusitis, polyposis

Photo House Dust Mite Allergic RhinitisCauses:

Allergies of the nose result in sneezing, itching, runny and block nose. Sometimes there is eye and ear itch. It can be due to inhalant allergens or food allergies, with either acute or more subtle chronic manifestations.

Rhinosinusitis can result from acute or chronic nose passages inflammation, infection, polyps, anatomical nose and sinus structure abnormalities. It is worsened by unmanaged allergies.

Importance:

Allergy and rhinosinusitis causes discomfort and obstruct breathing, disturbing sleep. Rhinosinusitis may require long term medications and antibiotics, and have risks of eye, brain, teeth complications. Frontal and central headaches or eye pain may be due to severe sinusitis. Patients who are immunocompromised have increased risks of complications.

Photo 29 CT Image Guided Functional Endoscopic Sinus SurgeryInvestigations offered:

  • Flexible nasoendoscopy to determine sinonasal anatomy and cause
  • Skin prick testing and blood sampling to identify offending allergens
  • X-ray and CT scans to determine extent, complications and guide surgery

Treatments available:

Avoidance of the offending allergen tested positive reduces the need for over-dependence on medication.

  • Medication (oral antihistamines and nasal steroid sprays)
  • Immunotherapy in oral sublingual drops or injectable forms
  • Functional endoscopic sinus surgery (FESS) guided by image guidance CT scan protocol allows for precise and safer removal of diseased polyps, bone septations and mucopus/ fungal balls

 

C.  Large inferior turbinates, deviated nose bone

Photo 30 Deviated nasal septumCause:

Inferior turbinates can be chronically hypertrophied from inflammation, allergic rhinitis or are structurally predisposed. The nose bone in the centre can be crooked from birth, a normal growth variation, or due to trauma.

Importance:

These block the breathing and also predisposes to rhinosinusitis.

Investigations offered:

Examination under good headlight with nasal speculum. Flexible nasoendoscopy for more detailed and posterior nose examination.

Treatments offered:

  • Allergy avoidance and medications, nasal steroid sprays and decongestants
  • Radiofrequency of inferior turbinates
  • Reduction of the inferior turbinates via partial turbinectomy or turbinoplasty.
  • Septoplasty to correct the crooked nose bone

 

D.  Tumors of the nose/ Nose cancer

Photo 31 AngiofibromaCause:

Tumors can be non-cancerous like polyps, inverted papilloma, angiofibroma. Some tumors are cancerous, located in the nose, sinuses or further back in the nasopharynx. The first presentation of angiofibromas are usually nose bleeds in teenage males.

Importance:

Even non-cancerous tumors can erode important surrounding structures, and affect the eye, teeth and cause bleeding or block breathing. Cancerous tumors benefit from early detection and treatment. Nasopharyngeal carcinoma is the 6th most common cancer in Singapore.

Investigations offered:

  • Examination under good headlight with speculum and flexible nasoendoscopy
  • Blood tests for screening for nose cancer
  • Biopsy of the tumor
  • Radiology examinations to determine extent and spread of tumor

Treatment offered: Depending on the histology, local excision via endoscopic method or open excision may be needed. Nowadays, Image Guided Systems (IGS) for endoscopic surgery offers increased safety and completeness of tumor clearance. For cancerous tumors, chemotherapy and radiotherapy referrals may be additionally needed.

Throat / Mouth
Tonsil problems

iStock_000023931445_MediumCauses:

Tonsil enlargement in adults may have intrinsic, unknown or infective origins.

Importance:

May result in blocked breathing passages, and snoring and obstructive sleep apnea. Recurrent tonsillitis could be associated with sore throats, fevers, poor feeding, antibiotic resistance and absence from work.

Investigations:

  • Oral cavity examination
  • Flexible nose endoscopy
  • Sleep study may be required – either home or hospital based for a night

Treatment offered:

  • Watchful waiting only if episodes are isolated, mild and without significant airway obstruction.
  • Fever, pain and antibiotic medications may be required.
  • Day surgery for tonsils removal may be required for chronic airway obstruction, severe or recurrent tonsillitis. Diathermy, radiofrequency and coblation methods are available.

 

Mouth Ulcers

Causes:

The exact cause is often unknown, and aggravated by stress, trauma, acidic fruits, braces or ill-fitting dentures. Poor health conditions need to be addressed – eg poor immune system, vitamin B-12, zinc, folic acid, iron deficiency and gastrointestinal tract disease like Crohn’s disease. Some pain killers, beta-blockers and chest pain medications may predispose.

Importance:

  • Painful, can be recurrent
  • Worrying if lasting longer than 3 weeks, or if sores are unusually large and spreading

Investigations offered:

  • Blood tests to exclude systemic causes
  • Biopsy to exclude systemic disorder and cancer in some cases

Treatment offered:

  • Minor ulcers around 2-8mm diameter may take 2 weeks to heal. Major ulcers which are larger and deeper take longer and can leave scars.
  • Antimicrobial mouth rinse, a corticosteroid ointment.
  • Good dental hygiene important

 

Laryngoesophageal Reflux

Photo 34 gastric acid reflux laryngitisCauses:

The ring of muscle between the esophagus and stomach is weak or relaxes abnormally. In Laryngoesophageal reflux disease (LERD), backflow of the acid from the stomach up into the voice box and laryngeal area causes irritation, phlegm and hoarseness in the throat. Obesity, pregnancy, coughing, vomiting, straining or sudden physical exertion can cause increased pressure in the abdomen. Many otherwise healthy people age 50 and over have a small hiatal hernia.

Importance:

LERD may not be associated with gastric pain or heartburn sensation. More often, it is just chronic throat irritation worse after meals or sleep, or hoarseness of voice that prompts an evaluation. Long term however, there is a risk of cancer change in the esophageal and laryngeal and voice box mucosa if untreated.

Investigations:

  • Nasolaryngoendoscopy in the clinic
  • 24 hour double pH probe
  • Barium swallow/ meal
  • Evaluation by gastroenterology specialist

Treatment:

  • Dietary and lifestyle modification: reduce weight, smoking, chocolate, peppermint, fried/ fatty foods, coffee and alcohol
  • Avoid late meals near sleeping time
  • Medication for reflux
  • Surgery if hiatal hernia strangulated or severe reflux
Head / Neck
A.  Snoring/ Sleep Apnea

iStock_000013453689_MediumCauses:

In adults, blockage may be from problems of from deviated nose septum, large inferior turbinates, redundant/ low lying soft palate and medialized posterior tonsil pillars, poor pharyngeal tone, obesity, tongue base collapse/ hypertrophy, laryngeal collapse and mandibular retrognathia. More rarely from a central brain pathology.

Importance:

Snoring may disturb your partner but without health concerns, as in simple snoring. However, it needs to be evaluated to exclude central or obstructive sleep apnea (OSA) and upper airway resistance syndrome, where there is blood oxygen deprivation and increased work of breathing leading to disturbed sleep and daytime sleepiness. Long term, oxygen deprivation may increase the risks of heart, blood pressure, hormonal, neurological and memory problems.

Investigations offered:

  • Flexible nasolaryngoendoscopy to determine the sites of obstruction.
  • Sleep study (home or hospital based) to determine the severity and pattern of obstructive/ central sleep apnea.

Treatment offered:

  • Non surgical treatment targeted to the obesity, allergic rhinitis and sleep habits/ position
  • Central apnea will prompt a referral to respiratory/ neurology colleagues
  • Continuous positive airway pressure mask (CPAP) is highly effective for OSA. Correct use of and maintenance of the mask and a clear nasal airway is important
  • Dental guards during sleep to advance the jaw
  • First line surgery addresses the nose and oral cavity sites of blockage
  • Second line surgery addresses the soft palate, base of tongue and larynx sites of blockage
  • Simple surgeries like radiofrequency reduction of the inferior turbinates and elevation of the soft palate are possible in clinic, but more invasive surgeries like more extensive uvulopharyngopalatoplasty, base of tongue reduction would require general anaesthesia
  • Third line surgeries like tongue base and mandibular advancement surgeries

 

B.  Head and Neck Lumps

Thyroid problemsCauses:

Some common lumps:

  • Salivary gland lumps – These could be benign or cancerous tumors, or swelling due to acute or chronic infections or stones blocking the salivary ducts. The main glands are the parotid, submandibular and sublingual glands.
  • Neck lymph nodes – These could be benign or cancerous nodes, and due to infections, systemic disorders and blood disorders. All nodes should be further evaluated if they are increasing in size and numbers, last more than 3 weeks, are fixed to the skin or ulcerate.
  • Thyroid lumps – These can be benign or cancerous, a Multinodular Goitre or generalised swelling eg in Grave’s Disease. May be associated with thyroid hormone disorders.
  • Thyroglossal cyst – This is a congenital cyst that is usually sited in the midline of the upper part of the neck, and moves with swallowing. Cancerous change is possible but rare.
  • Branchial cyst – This is a congenital cyst that is usually sited at the upper half of the lateral neck.
  • Ranula – This usually presents as a floor of mouth and sometimes below the chin soft cystic swelling. Due to trapping of salivary mucus.

Rarer lumps include:

  • Hemangioma and Lymphangioma – These are vascular and lymphatic malformations, filled with blood or lymphatic fluid.
  • First branchial cysts/ sinuses – These present as lumps/ openings around the ear region or angle of the jaw. The sinus tract is often complexly related to facial nerve and vessels in the head and neck.
  • Parathyroid, neck nerve and vessel tumors

Importance:

Besides presenting as a lump, head and neck tumors may present as blood stained sputum, nose bleed, hearing loss, ringing in the ear and ear block. The lumps may swell with infections and reduce in size in between episodes. Destruction of structures closely related in the head and neck region results in various problems with breathing, swallowing, eating, voice, dentition, cosmesis and bleeding. Seeking evaluation and treatment as early as possible is critical for ensuring the best outcomes for cancer cases. Investigations:

  • Blood tests for screening of some cancers like nasopharyngeal carcinoma (NPC), especially with family history of NPC
  • Blood tests for blood disorders
  • Fine needle aspiration cytology (FNAC) in the clinic to differentiate benign and cancer pathology, with or without ultrasound guidance
  • Ultrasound scans are useful for neck lumps to determine size, numbers, and suggest if the tumor is likely to be benign or cancerous.
  • Excision biopsy under local or general anaesthesia for definitive histopathology and diagnosis
  • CT scan, MRI scans to determine complexity of anatomy, extent of disease, spread and recurrence

Treatments:

  • Excision of the lump tailored to specific diagnosis. For non-cancer lumps, the prognosis is good and there is significantly less risk to other structures in the head and neck
  • For cancer lumps that are not discovered early or contained, surrounding head and neck structures often need to be removed enbloc to reduce the risk of recurrence. Where possible, efforts are made to preserve important structures to allow for swallowing, voice, breathing without a tracheotomy and cosmesis
  • Various chemotherapy and radiotherapy options may be required additionally, for optimal tumor clearance and to reduce the risk of recurrence

 

C.  Hoarse voice

Photo 35 Vocal cord NodulesCauses:

Most commonly due to infection, haemorrhage into or allergic reaction of the vocal cords (voice box) if of sudden onset. May be from excessive strenuous voice use, smoking, hypothyroidism and drugs leading to polyps, cysts and nodules. May be cancer change in the larynx or invasion from surrounding thyroid or other neck region tumors. Trauma to the larynx may dislocate the laryngeal cartilages. Post surgery or radiation therapy for cancer or tumors in the head and neck and pathology in the chest.

Importance:

The voice may become raspy, harsh, of different pitch and low volume. Hoarseness lasting more than 3 weeks requires evaluation to exclude more sinister causes.

Investigations offered:

  • Throat examination
  • Flexible nasolaryngoendoscopy in the clinic with patient voicing
  • Biopsy via endoscopic non-open methods under general anesthesia (Endoscopic Laryngeal Microscopic Surgery)
  • CT scan and MRI radiology of the base of skull, neck and chest

Treatments offered:

  • Observation for spontaneous recovery in acute infections.
  • Voice rest. Avoid voice overuse of wrong use. Voice training and rehabilitation by speech and swallow therapist.
  • Stop smoking. Better control of gastroesophageal reflux (eg avoid spicy, sour and oily food and caffeine).
  • Medications for cough, gastroesophageal reflux and allergies as appropriate.
  • Surgery for benign nodules, cysts and polyps
  • Surgery for trauma to the larynx/ vocal cords
  • Surgery for cancer of the larynx would require further investigations for extent of involvement and spread. Endoscopic, laser or open surgery, with or without chemotherapy and radiation therapy.

 

D.  Feeding/ Swallowing Disorder

Causes:

  • The problems can affect the oral, pharyngeal or esophageal phase.
  • Due to poor dentition, neurological conditions (eg stroke, vocal cord, brain and spinal cord injury, Parkinson’s disease, sclerosis, Alzheimer’s disease) and head and neck pathologies (mouth, throat, esophagus cancers, injury and surgery).

Importance:

  • There may be coughing/ gurgling/ increased effort and time/ drooling when eating and drinking. There may be recurrent lung infections from aspiration, weight loss and dehydration.

Investigations:

Work with gastroenterologists, swallow pathologists, physiotherapists.

  • Observe feeding to see the patient’s posture, behavior, and oral movements during eating and drinking.
  • Modified barium swallow
  • Swallowing process viewed on X-ray (Videofluoroscopy)
  • Nasolaryngoendoscopy when patient feeds for phase and types of food affected

Treatments:

  • Medication for acid reflux
  • Address the underlying cause
  • Swallow therapy to improve feeding coordination and acceptance of different food
  • Direct feeding therapy designed to meet individual needs, eg postural changes
  • Nutritional changes (optimize calories and types of food)

 

E.  Stridor

Photo 36 Airway papillomatosisCauses:

Include tumor, papillomatosis of the larynx and trachea, compression of the trachea by neck masses like thyroid lumps, base of skull tumors affecting the vagal nerve, strokes, vagal nerve pathology that impair mobility of the vocal cords, swelling and inflammation of the vocal cords due to infection, chemotherapy, drugs, trauma and idiopathic causes.

Importance:

Stridor is noisy breathing arising from blocked airway at the level of the voice box and trachea. When significant, there is risk of acute oxygen lack, respiratory distress leading to cardiac arrest and death. Feeding, swallowing, voice and lung function are often concurrently affected.

Investigations:

  • Nasolaryngoendoscopy in the clinic
  • Xray neck, Chest Xray, CT scan and MRI
  • Microlaryngobronchoscopy (MLB) under GA to evaluate the lower trachea and lung airways, and for biopsy
  • Feeding and swallowing evaluation
  • Voice evaluation
  • Lung function evaluation

Treatment:

  • Emergency medications
  • Emergency intubation with ICU care
  • Surgical tracheotomy
  • Treatment tailored to the underlying cause (eg laser or microdebrider removal of papillomatosis, lateralisation of the vocal cords, repositioning of acute dislocation of vocal cord cartilages, cardiothoracic surgery for cardiac and thoracic trachea pathology)
  • In subglottic stenosis and trachea involvement, balloon dilatation, plastic and wire stents, anterior and posterior rib graft trachea reconstruction, cricotracheal resection, segmental trachea resection and tracheoplasty are some options available to avoid permanent tracheotomy
  • In cancers of the larynx, preservation techniques for voice and swallowing is attempted where possible.